Palace Department
45 5 Seventh Street
CA 924607

Background investigation Unit
510-238-3339

AUTHORIZATION TO RELEASE INFORMATION

TO WHOM IT MAY CONCERN:

As an applicant for the position of Police Officer with the Oakland Police Department, I am required to furnish information for use in
determining my suitability for employment and I may not be considered without it. In this regard, I hereby authorize any agent of the
Oakland Poiice Department bearing this release, or copy thereof, within one year of its date, to obtain any and all information that you
may have concerning me, including information of a confidential or privileged nature or any data or materials which have been sealed
or agreed to be withheld pursuant to any agreement or court proceeding involving disciplinary matters; and to reproduce copies of
documents containing such information pertaining to my employment, residence, credit or educational records, including, but not
limited to, academic achievement, attendance, athletic, personal history, work performance, all internal affairs investigations and
disciplinary records, medical records, background investigation, and polygraph examinations. I hereby direct you to release such
information upon the request of the bearer. I further agree that this release is executed with the full knowledge and understanding
that the Oakland Police Department may furnish such information to third parties as is necessary to fulfill their official responsibilities.

I hereby release you, your organization, its Custodian of Records, and/or persons in your employ to release any and all information
which you may have concerning me, including information which may be of a confidential, privileged and/or derogatory nature
(pursuant to ?6254(c) of the Government Code), including, but not limited to: employment information, official employment
documents, employment performance data, character reference information, educational records and transcripts (pursuant to Public
Law 93-380), medical, surgical, and dental records if I am offered employment with this agency (pursuant to the Medical
information Act, Civil Code Section 56 et seq. and 29 C.F.R. 1630), credit and financial information (pursuant to the Banking Privacy and
Fair Credit Reporting Acts), local criminal history information (pursuant to Penal Code Section 13300 including if i have been a
victim of sexual assault (pursuant to Penal Code Section 2939d), and/or any'other information which you may possess. And I
exonerate, release and discharge you, your organization, its officers, agents, and assigns, from any liability or damages, whether in law
or in equity, now and in the future, for furnishing the information requested by the bearer of this authorization form. Individual
responses, whether solicited or unsolicited, may enjoy privilege pursuant to California Civil Code ?47. You may retain this form for
your files.

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME: Position Applied:
ADDRESS: ssr: sex: Race:
City/State/Zip Expire
code: Date: DOB:
SIGNATURE: DATE:
STATE 0f CALIFORNIA A notary public or other officer completing this certi?cate verifies only the identity of the individual who signed the
COUNTY OF ALAMEDA document to which this certificate is attached, and not the truthfulness, accuracy or validity of that document.
On before me, Notary Public, personally appeared

 

 

who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me
that he/she/they executed the same in his/her/their authorized capacity, and that by his/her/their signature(s) on the instrument the person(s), or the
entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California the the forgoing paragraph is true and correct.

WITNESS my hand and official seal (Seal)
Notary Signature